Mental health manual gets an update

    It’s the “book of books” for the mental health field, and it’s getting a make-over. A new edition of the DSM – the Diagnostic and Statistical Manual of mental disorders – is due out in 2013. Proposed changes have been posted online for comment. Some critics say they don’t go nearly far enough.

    It’s the “book of books” for the mental health field, and it’s getting a make-over. A new edition of the DSM – the Diagnostic and Statistical Manual of mental disorders – is due out in 2013. Proposed changes have been posted online for comment. Some critics say they don’t go nearly far enough. [audio:100308msdsm.mp3]

    About one in four American adults have a diagnosable mental disorder.

    Before each of those diagnoses was reached, the DSM was consulted. It’s a fat book with huge impact. Published by the American Psychiatric Association, it can determine which conditions get covered by insurance, what drugs get prescribed, which treatments ordered. It shapes mental health policy, research and fund-raising.

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    Dr. William Narrow, part of the DSM Five task force, describes what’s up for review:


    See the online version of the DSM V revisions.Narrow: What’s working about these diagnoses, what’s not working about these diagnoses, are they actually used at all in clinical practice, has there been any research that helps up to further understand these diagnoses

    The last edition was published in 1994, with an update in 2000, so there’s a lot of catching up to do.

    Some changes are cosmetic, such as a likely change from the term “mentally retarded” to “intellectually disabled.”

    But the new edition also has to take into account tremendous strides in brain research, and increasing subtlety in diagnosis. Right now, the DSM’s rigid categories don’t leave room for co-occurring symptoms such as depression and anxiety, so patients often end up with a laundry list of disorders.

    Narrow: We’re trying to address this issue by developing measurements that will allow a clinician to document a primary diagnosis and then also document the level of other associated symptoms without necessarily having to make multiple diagnoses on a single patient.

    This may not affect patients so much, but has implications for research.

    As editing continues, some disorders will be deleted, others added.

    But critics say these kinds of changes only scratch the surface, and don’t get to core issues of how mental illness is understood and researched. The DSM defines mental illnesses based on behaviors and mood.

    Gur: These are the features, this is the combination, this is how severe they are, and this is how long they lasted.

    That’s Dr. Raquel Gur, a scientist at the University of Pennsylvania. She studies schizophrenia. Gur is one of many scientists who worry that these behavior-based categories lag behind recent research into the biological and genetic causes of mental illness:

    Gur: The DSM is experts in the field that get together and reach a consensus. The brain doesn’t know about this, right? So the brain is very complex and sometimes when we categorize and we don’t consider the brain from a biological perspective, that you can’t divide it like that, we can miss important information.

    Defining illness mostly through behaviors can lead to misdiagnosis, says Alissa Bronsteen of New Jersey. Her teenage son has bi-polar disorder. Like many, he was first misdiagnosed as having Attention Deficit Hyperactivity disorder, and given the wrong medications. And that, Bronsteen says, could have catastrophic results:

    Bronsteen: You know these medications can seriously exacerbate a child’s condition, if you are prone to mania and you’re given an anti-depressant, you can become…. dead actually, you can commit suicide!

    She says her son gets excellent care right now, but today’s best efforts still fall short:

    It’s sort of like trying to steer the queen Mary with a paddle the meds just are not good enough to treat this very huge illness.

    Bronsteen heads a research foundation for juvenile bipolar disorder that is working on new ways to use biological markers to aid diagnosis of this mental illness. If that approach isn’t incorporated into the DSM, she says, it would delay finding treatments:

    Bronsteen: And the idea of another ten twelve years of not moving forward it just fills us with a desperate sense of dread because it will be another generation of children who will not progress.

    The National Institute of Mental Health has launched an effort to further the study of how biology and genetics connect to behavior.

    Dr. William Narrow from the DSM task force says those findings will inform future diagnostic criteria. He says integrating the science of behavior with new findings from brain research and genetics is a tough chore


    Dr. William Narrow of the DSM V Task Force, responds to criticism that the DSm should include biological and genetic definitions for mental disorders, not just behavior:

    Psychiatry as a clinical discipline will always be based on behavior; these are the kinds of disorders we evaluate and treat. All of medicine has its basis in the clinicial signs and symptoms of its patients. So the issue is how to connect the behavioral symptoms that our patients exhibit with the rapidly advancing findings from the fields of neuroscience and genetics, and integrate them into methods for clinical diagnosis. The NIH sponsored the American Psychaitric Institute for Research and Education to develop a series of 13 conferences, prior to the start of the DSM revisions, in part to examine these issues. For the most part, it is too early to make these connections in DSM-5, but we have made some proposals that reflect new research findings and are expected to facilitate new research in ways that were not possible when using DSM-IV criteria.

    First, we recognize that research is guiding us in directions that indicate that mental disorders are not as clear-cut as the rigid categories of DSM-IV would indicate. Clinically we know that patients with a particular primary disorder, schizophrenia for example, often have symptoms of many other disorders: sleep problems, anxiety, depression, and so forth. DSM-5 proposes to make it easier to capture these diverse symptoms in a psychiatric evaluation. This will not only benefit clinicians, but also give researchers greater freedom to explore the full range of symptoms that may be present in patients with the disorders that they are studying .

    Second, DSM-5 developers are examining different ways to group the disorders in the manual that reflect new research findings and may facilitate further research. For example, research is showing us relationships between disorders based on neurocircuitry, genetics and behavioral manifestations that are posing opportunities for grouping disorders on that basis. Examples include addictive disorders (including not only substance use but also such behaviors as pathological gambling), fear circuitry-based disorders such as panic disorder and phobias, and obsessive compulsive spectrum disorders that might include not only obsessive compulsive disorder, but also tic disorders and hypochondriasis. New groupings of disorders are powerful indicators of our current knowledge, but also will point the way for new research.

    Finally, it is relevant to mention that the National Institute of Mental Health has started an initiative called RDoC (Research Domain Criteria) that will focus on the neurocircuitry and genetics underlying common behaviors. This effort will be very useful and complementary to the development of future DSM diagnostic criteria.

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